Dauzier and Thibault of France were the first to report on “Fertilization in vitro of rabbit oocyte” in 1954. Chang and Bedford confirmed their findings in 1959, following which Yanagimachi and Chang reported on “Fertilization of hamster eggs in vitro” in 1963. Two years later Edwards reported the “Maturation in vitro of mouse, sheep, cow, pig, rhesus monkey and human ovarian oocytes.” The first clinician, Patrick Steptoe, entered the scene in 1968 when he started to collaborate with Edwards; this association enabled them to perform important studies using human gametes: “Early stages of fertilization in vitro of human oocytes matured in vitro” (1969), “Fertilization and cleavage in vitro of preovulatory human oocytes” (1970), and “Human blastocysts grown in culture” (1971).

The vision and driving force behind the human work was Bob Edwards. The first human pregnancy derived from in vitro fertilization (IVF) was a tubal pregnancy in 1976. The first baby conceived in vitro was born, by cesarean section, on July 25, 1978, just before midnight. Both events were reported by Steptoe and Edwards in the Lancet; the birth of the first IVF baby was reported immediately and with great fanfare by the world media.

During the first decade that followed this event, the IVF results remained fairly modest. The first international survey carried out in 1984 by Markku Seppala reported a delivery rate per initiated cycle of only 5.4%. This rate remained under 12% until the end of the decade. My team and I, in Vancouver, were fortunate to have the first baby conceived in vitro in Canada; he was born on December 25, 1983.

The nineties brought sunshine to IVF; the success rate improved gradually, and by the end of the decade the rate of delivery per initiated cycle, in the USA, reached 25.4%. In 2003, the last reported year, this rate was 28%. It is interesting to note that improvement in outcomes was realized without any change in the cancellation rate, which remained around 13 to 14%.

Intracytoplasmic sperm injection (ICSI) also started with animal experimentation by Gianpiero Palermo and co-workers. Their initial report in 1991 “Enhancement of acrosome reaction and subzonal insemination of a single spermatozoon in mouse eggs” was followed by work on human oocytes that led to a report in 1992 “Induction of acrosome reaction in human spermatozoa used for subzonal insemination”. During the same year, Palermo and associates were also able to report on pregnancies in human subjects: “Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte”.

The introduction of ICSI has dramatically changed treatment of male infertility. The 2003 USA results clearly confirm the results of previous years, that the delivery per oocyte pick-up (OPU) rates are fairly similar between couples with male factor and those without male factor treated with IVF plus ICSI.10

The significant improvement in outcomes was due to the simplification of clinical and especially the simplification and standardization of laboratory techniques; the improvements in cryopreservation of supernumerary embryos, the advent of intracytoplasmic sperm injection (ICSI), and to the industrialization of IVF services. This improvement came about at the expense of a very high rate of multiple pregnancies, especially triplets and higher order of multiples, as a result of replacement (transfer) of multiple embryos.

Multiple pregnancies are associated with a higher incidence of obstetrical complications and neonatal complications and deaths. They incur significant costs to the society, associated with the care of premature and sick infants, and tax the parents financially and emotionally. Fortunately, there is now a growing movement to decrease the number of embryos transferred, and to individualize the number taking into account the woman's age the quality of available embryos and other pertinent parameters.

Assisted Reproductive Technology (ART) which includes IVF has had a tremendous impact in the practice of reproductive medicine. It made IVF possible for a significant proportion of women, who otherwise would not achieve a pregnancy, to bear children. It has permitted the introduction of prenatal genetic diagnosis (PGD), enabling couples who are carriers of genetic disease to have healthy children.

We must be reminded that, despite the impressive progress in outcomes, ART fails to yield an offspring for approximately 50% of couples willing to undergo 3 cycles of treatment. And many do not persist that long. The industrialization of IVF proved to be a two edged sword. On the one hand, it has permitted ready access to this form of treatment globally, while on the other it funnels to IVF many couples who would benefit from simpler forms of treatment. It has caused significant reduction in the use and teaching of reproductive microsurgery. The reestablishment of a balanced approach remains the responsibility of the teaching institutions.

The selection of the initial and subsequent treatment modalities, for a given infertile couple, must be individualized on the basis of the findings obtained from a proper investigation. Reconstructive surgery and ART must not be viewed as competitive techniques; instead, they should be accepted and used as complementary methods to achieve a greater rate of success in patients presenting with complex fertility problems. There is ample evidence in this regard.

IVF has also opened many areas of investigation and progress: stem cell research, gene therapy, therapeutic cloning, etc. It is also opening the Pandora box of human cloning. Such is the destiny of scientific research.

Progress is made by visionaries who are willing to push the envelope; visionaries who have the will to stay the course, and the strength to withstand the abuse from those who fear change.

I am honored to be asked to contribute a foreword to this “Atlas of Human Assisted Reproductive Technologies” edited by Dr. Mangala Telang. This is a concise, practical and richly illustrated book, designed for those involved in the practice of ART, and the personnel working in ART laboratories.

The book is divided into three sections: clinical aspects of ART, laboratory aspects of ART, and new developments. The initial chapter of the first section is authored by Dr. Telang and devoted to the female partner. The chapter commences with a detailed discussion of the evaluation of the female partner, which is so important in selecting the most appropriate treatment. The second part of the chapter covers important clinical aspects of assisted reproduction including controlled ovarian stimulation, ovum pick-up and transfer, etc. The subsequent four chapters that complete the first section ably discuss the evaluation of the male partner, non-surgical and surgical methods of sperm collection, and the role of ultrasound in ART.

The second section commences with a chapter that discusses the laboratory, its equipment, quality control and assurance. The subsequent seven chapters in this section provide a detailed description of the various laboratory 11techniques: sperm preparation, culture, ICSI, cryopreservation, PGD, etc. The last section, “new developments” include three chapters devoted to in vitro maturation, stem cells, and vitrification.

The balance and clarity of the book reflects the expertise and wisdom of its editor Dr. Mangala Telang who selected its authorship, and crafted and edited its contents. I am certain that it will prove to be a very useful guide to those involved in the practice of ART, personnel working in ART laboratories, and undoubtedly residents in gynecology.

There was no atlas in the Indian market which would explain pictorially all the facets of clinical and laboratory management of ART. The atlases available from outside India were very expensive for Indian laboratories and this is an attempt to make such a book available for all ART laboratories. All the authors are very renowned and experienced in their own fields of expertise which they have shared in this atlas.

There is a comprehensive section on clinical aspects, which describes in detail the evaluation of an infertile woman and the management of various problems which could affect her fertility.

There are chapters which handle male infertility comprehensively.

Apart from the routine ART, latest advances in cryopreservation, in vitro maturation, vitrification have been contributed by very experienced scientists. The latest interest in stem cell research has also been addressed.

I hope this atlas finds a place in every IVF laboratory and is found to be useful both by the clinician and the laboratory personnel.

I am grateful to all the contributors for making special efforts to make their text meaningful by adding their personal experiences in the form of pictures.

I am thankful to Sudesh A Kamat for helping me to contact contributors from various parts of the country.

My special thanks to Dr Ashok Khurana and Dr Narendra Malhotra for lending some of their pictures.

I have to acknowledge the valuable help given by Vishal Mittal with the computer work.

Last but not the least I have to thank my husband Dinbandhu for his understanding and encouragement always and Nandita and Sucheta for being bare for me.

Shri Jitendar P Vij gave me the idea to bring out an atlas and I thank him and Jaypee Brothers Medical Publishers for the excellent work they have done with the editing and printing.